U.S. Living Will Registry® Registration Agreement
Source Code
37125901
Registrant’s Identifying Information (Please type or print clearly) Name: First______________________ Middle______________________Last ______________________________ Suffix ______ Social Security Number:___________ ______ ____________Date of Birth: Month ___ ___Day______Year________ (4 digits, please) ________ Address - Primary Residence: Street Address ______________________________________________ Apt #____________________ City ________________________________________________________________ State ______ Zip Code ______________ Secondary Residence (if any): Street Address__________________________________________________________________Apt #____________________ City ________________________________________________________________ State________ Zip Code ________________ Phone- Home: ( ) __________________ Work: ( )_______________ _______________Secondary Res: ( )______________________
Emergency Contact #1: Name:________________________________________________________ Relationship:__________________________ __________________________ Address:______________________________________________________________________________________________________________________ Telephone Number: Home: ( )______________________________Work/Other: ( )__________________________________________
Emergency Contact #2: Name:________________________________________________________ Relationship:__________________________ Telephone Number: Home: ( )____________________ ______________Work/Other: ( )__________________________________________
I,____________________________________________________________________ ("Registrant" or “I”), request that the U.S. Living Will Registry®, with offices at 523 Westfield Ave., PO Box 2789 Westfield, New Jersey 07091-2789 (“Registry”), electronically store a copy of my attached advance directive (collectively, including but not limited to my: living will, health care proxy, or similar document[s], including organ donor information, provided to the Registry), and provide a copy of the stored advance directive image to any health care provider who requests it in conjunction with my care. A “health care provider” is any hospital, doctor, skilled nursing facility, nursing facility, home health care agency/provider, ambulatory surgery facility, hospice, or any authorized employee, contractor or agent of any of the foregoing, or other person believed charged with giving effect to my advance directive or assisting in same. I voluntarily execute this registration on the date set forth below, without coercion, duress or undue influence from any party, and I warrant and represent that I have the legal capacity to offer my consent to such registration. My registration is not effective until I receive written confirmation from the Registry, at the above address. I can only register through a Registry member Health Care Provider or a Registry Community Partner. The Registry’s member Health Care Providers and Community Partners are not owned or operated by the Registry, and they cannot change any terms of this Registration Agreement; any oral changes are not effective. Only the Registry can change the terms of the Registration Agreement, and only in writing (except in emergencies, in the Registry’s sole discretion). I have provided my Social Security number to facilitate the identification, retrieval and provision of my stored advance directive images to health care providers, and for the Registry’s recordkeeping purposes only. I. Registration and Certification: I submit the information contained herein to confirm my identity, in the event that a health care provider requests a copy of my advance directive. I certify that this information is correct and that the attached advance directive is my currently effective advance directive, which was properly executed in accordance with the laws of the state where it was executed. If the attached advance directive is a copy, I certify that it is a true and correct copy of the
original document. I agree to immediately notify the Registry, in writing, at the Registry’s address listed above, in the event of my revocation of the attached advance directive or of this registration, or if the attached advance directive or the identifying information herein are changed in any way. I agree immediately to provide the Registry with a copy of the new/changed documents. I will indemnify and hold the Registry harmless for any damages resulting from the Registry’s reliance on these certifications, or on any inaccurate information I supplied. If I don’t notify the Registry in writing and in a timely manner of any changes, or of the revocation of my advance directive or this registration, or if I don’t provide a true copy of the changed documents to the Registry, the Registry will not be liable for any damages resulting from the production of the documents on file to any health care provider. If my information is accessed over the Internet utilizing my unique registration number, my social security number (“SSN”) will not be revealed, and it will not be visible or disclosed on the Registry’s web page. If the card containing my unique registration number is lost or otherwise unavailable, health care providers will be able to access my documents using my SSN. Since most health care providers have access to their patients’ SSN, providing your SSN to the Registry ensures the widest availability of your advance directive images to health care providers in time of need, even when your card is not available. The Registry will take appropriate steps to safeguard the privacy and confidentiality of each Registrant’s SSN, and the Registry will not use SSNs for any purposes not specifically permitted by this Registration agreement. If you do not provide your SSN, your documents will be identified only by the unique registration number assigned by the Registry, which will significantly limit the accessibility of your documents. II. Authorization: I authorize the Registry to send a copy of my advance directive to any health care provider (as defined herein) that requests a copy of it, provided the request conforms to the Registry’s policies and procedures (or as deemed advisable by the Registry in an emergency situation, or as required by law). The Registry is not otherwise authorized to share my personal information with parties other than health care providers (as defined herein). A copy of this Agreement may be used in place of the original document. III. Limitations on Liability: I understand that I will not be charged a fee to register or to maintain my registration. Registry shall not be liable to me or any person or entity for any liability arising from the improper transmission/disclosure of my advance directive, from the transmission of inaccurate or incomplete materials, or from the loss/misplacement/destruction/unavailability of all or part of my advance directive. If I don’t agree to these terms, I am free not to use the Registry’s service. IV. Term: This Agreement shall remain in effect until Registry receives reliable information that the Registrant is deceased, the Registrant requests, in writing, that the Agreement be terminated, or until registration is cancelled pursuant to the Registry’s policies and procedures. When the Agreement is terminated, Registry will use best efforts to remove Registrant’s advance directive from its files. I hereby agree to the terms herein, and certify the accuracy of the information provided. I agree to safeguard my Registration ID card from unauthorized access. I understand that anyone who gains access to my card can use it to gain access to my documents and personal information (but not to my SSN), and I will not hold the Registry liable for such unauthorized access.
X______________________________________________________________________ DATED: _____/_____/_____ Signature of Registrant
WITNESS STATEMENT I declare that the Registrant who signed this document is personally known to me, that he/she signed or acknowledged this document in my presence, and that he/she appears to be of sound mind, and under no duress or undue influence. Signature: _______________________________________Print Name: _______________________________________ (Witness #1) DATED: _____/_____/_____ Signature: _______________________________________Print Name: _______________________________________ (Witness #2) DATED: _____/_____/_____